医药医保政策改革下的江苏省医保基金运行绩效研究

目的:评估江苏省医药医保关键改革政策前后,13城市医疗费用及医保基金运行情况,探讨改革对医保基金的影响。方法:采用文献复习法和专家访谈法相结合,建立医保基金运行绩效体系。基于评价体系,对改革前后江苏省13城市医保基金运行绩效评价。医疗费用及医保基金运行数据分别来源于卫生、医保部门统计数据。结果:在改革中,江苏各地因地区经济发展水平、医保支付方式、医疗保障水平、分级诊疗推进程度等不同,医保基金运行绩效有所差异。结论:通过加大医疗成本控制、探索科学医保支付,推进分级诊疗、发挥临床药师作用等方式,巩固医药医保相关改革成效、提升医保基金运行绩效。

Study on the Operation Performance of Medical Insurance Funds in Jiangsu under the Medical and Drug Insurance Policy Reform

Objective:To evaluate the medical expenses and the operation of 13 cities’medical insurance funds before and after the related reform policies in Jiangsu Province and to analyze the impact of the reforms on medical insurance funds.Methods:The literature review and expert interview method are used to establish the evaluation system of medical insurance fund operation.Based on the evaluation system,it evaluates the 13 cities’medical insurance funds in Jiangsu Province before and after the reform.The data of the medical expenses and medical insurance fund operation come from the statistics of health and medical insurance departments.Results:During the reform process,the medical insurance fund operation is different in 13citiers due to different regional economic development levels,medical insurance payment,medical security levels and the advancement of hierarchical treatment.Conclusion:Increasing the control of medical costs and exploring scientific medical insurance payment are needed to promote hierarchical treatment,play the role of clinical pharmacists,consolidate the reforms and improve the performance of medical insurance funds.